Provider Alerts

Formulary Update

Effective 9/16/2014, the Pharmacy and Therapeutics Committee has approved the following changes.

1. Rabeprazole (Aciphex) – Prior authorization (PA) required. Reserved for documented treatment failure of 2 (two) dose-optimized first-line therapies (omeprazole, pantoprazole, lansoprazole) AND Nexium OTC 40mg or higher.
2. Dexlansoprazole (Dexilant) – PA required. Reserved for documented treatment failure of 2 (two) dose-optimized first-line agents (omeprazole, pantoprazole, lansoprazole), Nexium OTC 40mg or higher, AND rabeprazole 20mg or higher.
3. Beclomethasone (Beconase AQ) – Step therapy (ST) required. Reserved for treatment failure of an adequate trial (7-14 days) of any 2 (two) first-line agents (fluticasone, flunisolide, Nasacort OTC).
4. Budesonide (Rhinocort Aqua) – ST required. Reserved for treatment failure of an adequate trial (7-14 days) of any 2 (two) first-line agents (fluticasone, flunisolide, Nasacort OTC).
5. Mometasone (Nasonex) – ST required. Reserved for treatment failure of an adequate trial (7-14 days) of any 2 (two) first-line agents (fluticasone, flunisolide, Nasacort OTC) AND one second-line agent (Beconase AQ, Rhinocort Aqua).
6. Adalimumab (Humira), Etanercept (Enbrel), Golimumab (Simponi) – Additional indication for psoriatic arthritis (PsA) and ankylosing spondylitis (AS): PA required. Reserved for treatment failure to at least one oral DMARD for 3 months (i.e. methotrexate, leflunomide, cyclosporine, sulfasalazine). Must be prescribed by rheumatologist or dermatologist and have radiographic evidence of disease.
   Note: No change in criteria for Crohn’s disease, Psoriasis, or Rheumatoid Arthritis.
7. Infliximab (Remicade) – Additional indication for PsA and AS. PA required. Reserved for treatment failure to at least one oral DMARD for 3 months (i.e. methotrexate, leflunomide, cyclosporine, sulfasalazine) and one 1st line agent (Enbrel, Humira). Must be prescribed by rheumatologist or dermatologist and have radiographic evidence of disease.
   Note: No change in criteria for Crohn’s disease, Psoriasis, or rheumatoid arthritis.
8. Ustekinumab (Stelara) – Additional indication for PsA. PA required. Reserved for treatment failure or intolerance to 1st line (Enbrel or Humira) and 2nd line (Remicade) therapy. Must be prescribed by rheumatologist or dermatologist and have radiographic evidence of disease.
9. Januvia, Onglyza, Tradjenta, pioglitazone, Invokana, Byetta, Victoza – In addition to current criteria, a trial of metformin extended release (ER) is now required for gastrointestinal-related intolerance to metformin immediate-release.

1. Esomeprazole (Nexium OTC) – PA required. Reserved for documentation of treatment failure of 2 (two) dose-optimized first line agents (Omeprazole 40mg or higher, Pantoprazole 40mg or higher, Lansoprazole 60mg or higher).
2. Triamcinolone Nasal Spray (Nasacort OTC) – Add to formulary with no PA required.
3. Fluticasone Furoate (Veramyst) – PA required. Reserved for use in 2-4 year olds with treatment failure to Nasacort OTC.
4. Apremilast (Otezla) – PA required. Reserved for diagnosis of PsA and treatment failure of two trials of dose-optimized DMARDs (3 months each). To be used concomitantly with a DMARD (i.e. methotrexate, leflunomide, cyclosporine, or sulfasalazine). Must be prescribed by rheumatologist or dermatologist and have radiographic evidence of disease.
5. Methotrexate Sodium P/F 25mg/ml 2ml-vials (NDC: 63323-0121-02; 61703-0350-38) – Add to formulary with no PA required. Restricted to 8ml per 23 days.
6. Empagliflozin (Jardiance) – ST required. Reserved for inadequate response to an adequate trial of metformin (unless contraindicated) in patients without severe renal impairment. A documented trial of Metformin ER is required if metformin IR cannot be tolerated due to gastrointestinal side effects. Limit 1 tablet per day.
7. Dapagliflozin (Farxiga) – ST required. Reserved for inadequate response to an adequate trial of metformin (unless contraindicated) in patients without severe renal impairment AND failure/intolerance to Invokana or Jardiance. A documented trial of Metformin ER is required if metformin IR cannot be tolerated due to gastrointestinal side effects. Limit 1 tablet per day.
8. Canagliflozin/Metformin (Invokamet) – Add to the formulary with no PA required. Limit 2 tablets per day.
9. Afrezza (inhaled insulin) – PA required. Reserved for treatment failure to 2 (two) dose-optimized rapid-acting injectable insulin (3 months each). Normal FEV1 at baseline is required. Concurrent use with basal insulin is required. For prior authorization renewal, must submit most recent HbA1c as well as annual PFTs. A decline in FEV1 of >20% will prompt discontinuation of Afrezza.
10. Dimethyl Fumarate (Tecfidera) – PA required. Reserved for treatment failure of Avonex, Copaxone, Rebif, or Betaseron. Restricted to patients with a verified diagnosis of MS with therapy initiated by a neurologist. Restricted to specialty pharmacy. Limit 60 capsules per month.

The following products will be removed from the formulary as of November 15th, 2014